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1 Myofascial Trigger Point Therapy Patient Medical History Form Please complete this form before your Initial Myofascial Trigger Point Therapy Evaluation and bring it with you to your appointment. Thank you. Patient Name: _ Date: Address: DOB: Phone: Emergency Contact and Phone: Where did you hear about The Tomo Touch? Medical History How long have you had Chronic Muscular Pain (and/or Fibromyalgia)? When did you notice the symptoms? Was there an event or illness that started the pain? Please list any accidents (e.g. car, bicycle) or surgeries you have undergone, starting with the most recent: Date of accident/surgery Accident/Surgery Have you been told by a physician that you have the following: Herniated or Bulging Disks 1

2 Diabetes Spinal Stenosis Scoliosis Thyroid problems Do you currently wear shoe orthotics? If yes, how long have you been wearing them? Do you now, or did you as a child, prefer to sit on one leg? Do you have any food sensitivities? If yes, please list: Please circle other therapists you are currently seeing or have seen in the past: Chiropractic Physical Therapy Acupuncture Massage Other: List any medications you are currently taking: List any medications you have tried in the past and the reason you stopped taking it: Personal Wellness What are your goals to improve the quality of your life? 2

3 Patterns/Body Chart Refer to the body chart below. Shade in the area(s) where you are experiencing pain. You can draw lines to indicate specific regions, or add any descriptive words to specify what you are feeling in that region, e.g., burning, sharp, shooting, dull, aching, numbness, tingling. Right Side R L L R Left Side Does anything increase your pain? If yes, please explain. Does anything relieve your pain, e.g., medication, heat, cold? Is the pain associated with any movements you make? 3

4 Do you experience any pain in the morning? If so, please describe. Does the level of pain increase, decrease, or stay the same in the evening before bed? At certain times of the month/week does your pain change? If so, how? Does your pain change with the weather? Work Stress Are you able to work? If yes, what is your occupation? Is your pain affecting you at work? If so, please describe. Do you perform repetitive movement at work? Are you immobile for long periods? How do you feel after a day of work? Home Stress Do you have childcare or home-tasks? Are you immobile for long periods? Do you read while laying on a couch/bed? Exercise/Stress Are you able to exercise? If yes, what type of exercises do you do and how frequently? Please be specific. 4

5 If not, what are your reasons for not exercising? What kind of exercises do you think you would enjoy doing? How stressed are you from day to day (please circle)? High High-Medium Medium Medium-Low Low Sleep What position do you most often sleep in? (circle) Back Side Stomach Arms overhead Half-stomach/half side Fetal position Pets in bed Spooning with partner If you sleep on your back: Do you use pillows under the knees? If you sleep on your side: Do you use any pillows between the legs? Do you use any pillows at the chest? How often do you sleep in each position? Are there any reasons you sleep in these positions? _ How many hours of sleep do you typically get? Do you have difficulty falling asleep? Do you wake up often in the middle of your sleep? Yes/no Do you wake up feeling tired? Smoking/Alcohol/Caffeine/Sugar Do you smoke or use tobacco products? If yes, what kind and how much per day? 5

6 Do you drink alcohol? Do you drink caffeinated beverages? Do you drink juice? Do you frequently eat food with high amounts of sugar/carbohydrates? Water/Supplements How much water do you drink a day? Please list any vitamins, minerals, and supplements you are currently taking: Jaw/Facial Pain Do you have TMJ Disorder? Do you have jaw pain associated with chewing or yawning? Do you clench or grind your teeth? Do you wear bifocals/trifocals? Do you wear a night guard or mouth splint? Yes/No Thank you for taking the time to complete this form. I look forward to working with you on your journey toward better health! 6

1 NECK PAIN Patient Name In order to properly assess your condition, we must understand how much your NECK/ARM problems has affected your ability to manage everyday activities. For each item below, please

PAIN MANAGEMENT Please fill out the following questionnaire and bring it with you to your appointment. In addition, bring your medication list and Reports of any X- rays, MRI or Cat scans. Patient s name:

What area hurts you the most? (Please choose one) When did this pain start? Neck Other: Back How did this pain start? How often do you experience this pain? Describe what this pain feels like. What makes

Copyright 2009 American Academy of Orthopaedic Surgeons Cervical Spondylosis (Arthritis of the Neck) Neck pain is extremely common. It can be caused by many things, and is most often related to getting

Medicare Insurance Registration Form (Page 1) Welcome to our Office: By completing this patient information form, you will help us to serve you more efficiently. Should you have any questions concerning

General Information about Sleep Studies and What to Expect Why do I need a sleep study? Your doctor has ordered a sleep study because your doctor is concerned you may have a sleep disorder that is impacting

Medical Registration Form (Page 1) Welcome to our Office: By completing this patient information form, you will help us to serve you more efficiently. Should you have any questions concerning our professional

Patient Information Form Pain Management Center at Phoebe Please complete the following form, so that we may facilitate your visit Occupation: or (circle) Retired, Disabled Homemaker, Full time student

Because multiple myeloma is a cancer involving the bone marrow, a common myeloma symptom is bone pain. But the good news is that most pain can be managed. This resource can help you better understand pain

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Castleknock GAA club member and Chartered Physiotherapist, James Sherry MISCP, has prepared an informative article on the common causes of back pain and how best it can be treated. To book a physiotherapy

X-Plain Preparing For Surgery Reference Summary Introduction More than 25 million surgical procedures are performed each year in the US. This reference summary will help you prepare for surgery. By understanding

Cervical Spine New Patient Form Please mark the painful areas on the pictures below Use the following marks: stabbing pain ooo burning pain +++ aching pain pins and needles = = = numbness Right Right Right

SLEEP QUESTIONNAIRE AND WAKEFULNESS (SQAW) PATIENT: DOCTOR: DATE COMPLETED: Must Be Completed by Appointment Date 7423-029-W-BKLT 11-1-09 For questions to be answered on a scale of 1 to 5, please circle

*2PHT* 2PHT Page 1 REHAB SERVICES PATIENT HISTORY QUESTIONNAIRE In order for us to fully address all aspects of your problem, the following information is needed. Please take time to complete this form.

Cancellation/No Show Policy If you are unable to keep your scheduled appointment we require a 24 hour advance notice. Failure to provide this notice will result in a $50.00 cancellation/no show fee. You

Name, Today's Date Accident Date Please answer the following questions as accurately and honestly as possible. This fonn is very important and will aid your doctor in providing you the best ~ as well as

Sciatica Yuliya Mutsa PTA 236 Sciatica is a common type of pain affecting the sciatic nerve, which extends from the lower back all the way through the back of the thigh and down through the leg. Depending

VANCE CHIROPRACTIC PERSONAL INJURY QUESTIONAIRE (PLEASE BE VERY SPECIFIC WITH YOUR ANSWERS THANK YOU!) Last Name First Name Middle Home Phone Work Phone Street Address and Number Mailing Address if Different

BEFORE SURGERY What should I do to prepare for my surgery? Arrange for a family member or friend to accompany you to the hospital on the day of your surgery. Cancel any dental appointments that fall within

EASTERN CONNECTICUT REHABILITATION CENTERS PHYSICAL THERAPY INFORMATION PACKET THANK YOU FOR CHOOSING ECRC-PT THIS PACKET INCLUDES IMPORTANT INFORMATION TO ASSIST IN YOUR RECOVERY AND UNDERSTANDING ABOUT

TB Get the Facts About Tuberculosis Disease What s Inside: Read this brochure today to learn how to protect your family and friends from TB. Then share it with people in your life. 2 Contents Get the facts,

Preparation guidelines for your Child s Sleep Study Patient Sticker here Maintain your child s regular night sleeping and nap schedule for several days before the study. On the day of the study, do not

Neck Injuries and Disorders Introduction Any part of your neck can be affected by neck problems. These affect the muscles, bones, joints, tendons, ligaments or nerves in the neck. There are many common

ANESTHESIA & YOU Anesthesia for Ambulatory Surgery T oday the majority of patients who undergo surgery or diagnostic tests do not need to stay overnight in the hospital. In most cases, you will be well

Shine Integrative Physical Therapy Intake Form First name Middle Last Birthdate / / How did you hear about us? Address City State Zip Home phone Cell phone Email address Occupation Emergency contact Phone

Preventing & Treating Low Back Pain An Introduction to Low Back Pain Low back pain is the number two reason that Americans see a health care practitioner second only to colds and flu. While most people

Date / / Name,, Last First MI DOB Age Current Occupation Home Phone Work phone Cell Phone Ethnicity : White Hispanic Asian African American American Indian Pacific Islander Other What is your primary language?

sleep handbook Keep this by your bedside to help you get straight to sleep. BEDSIDE BUDDY Chiropractic how can it help me get straight to sleep? Chiropractic is based on the scientific fact that the human

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CHIROPRACTIC WELLNESS AWARENESS Do you want to have a healthy body? Do you like to maintain your high energy level? Do you want to be stress-less? Do you like to be pain free? Please call Conrad Nieh D.C.